Courtyards Comm Living Center

Inspectors wroteBased on observations, staff interviews, facility document review, and record review, the facility failed to ensure comprehensive Activities of Daily Living (ADL) care plans were developed and implemented for two (2) of eighteen (18) residents reviewed. Specifically, the facility failed to develop a comprehensive ADL care plan addressing nail care needs for Resident #8 and failed to implement established ADL care plan interventions related to nail care for Resident #45. The scope and severity for this deficiency were cited at an E due to previous citations of F656 on the last two annual recertification surveys completed on 2/20/24 and 5/22/25 representing a pattern of deficiency.

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to provide activities of daily living (ADL) care necessary to maintain personal hygiene for two (2) of sixty (60) residents observed. (Residents #8 and #45)The scope and severity for this deficiency were cited at an E due to previous citations of F677 on the last two annual recertification surveys completed on 2/20/24 and 5/22/25 representing a pattern of deficiency.

Inspectors wroteBased on observation, staff interviews, record review and facility policy review the facility failed to maintain infection control practices by failing to ensure respiratory equipment was stored in a sanitary manner to prevent contamination (Resident #30) and by failing to ensure soiled items were properly discarded (Resident #55) for two (2) of eighteen sampled residents. The scope and severity for this deficiency were cited at an E due to previous citations of F880 on the last two annual recertification surveys completed on 2/20/24 and 5/22/25 representing a pattern of deficiency. Findings Include: Review of the facility policy titled, Infection Control Policy and Procedure, undated, revealed Purpose: [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to ensure the residents were treated with dignity and respect by failing to maintain privacy during the provision of care for one (1) of 18 sampled residents.

Inspectors wroteBased on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to ensure a clean homelike environment for one (1) of 38 resident rooms. Resident #2Findings Include: Record review of facility policy titled Cleaning and Disinfection of Environmental Services revised August 2009 revealed, .14. Horizontal surfaces will be wet dusted regularly (e.g., daily, three times per week) using clean cloths moistened with an EPA-registered hospital disinfectant (or detergent). The disinfectant (or detergent) will be prepared as recommended by the manufacturer . In an interview on 5/18/2026 at 12:30 PM, Resident #2 stated that her room was dusty and she needed to clean it herself. Resident #2 stated she also needed to clean the bathroom. When asked if housekeeping staff cleaned her room, Resident #2 stated they only removed the trash. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (1) of eighteen (18) residents reviewed. (Resident #21)

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plans for two (2) of the twenty-four resident care plans reviewed. (Resident #8 and Resident #53). The scope for F 656 was increased to E due to a prior citation on the last annual recertification survey on 2/20/24, which represents a pattern of deficiency.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) care for two (2) of 24 residents (Residents #8 and #53) observed during the initial tour. Specifically, the facility failed to ensure nail care was provided for Resident #8, failed to provide shaving for Resident #53, and failed to provide showers for both Residents #8 and #53 in accordance with their scheduled care routines and facility policy. The scope for F 677 was increased to E due to a prior citation on the last annual recertification survey on 2/20/24, which represents a pattern of deficiency.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure sufficient nursing staff were available to meet the Activities of Daily Living (ADL) needs of dependent residents, as required by the residents' care plans and the facility's staffing policy. This failure resulted in two (2) of 61 sampled residents (Resident #8 and Resident #53) not receiving scheduled showers, hygiene care, and nail care.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review, the facility failed to make prompt efforts to resolve a grievance from resident Council meetings and communicate steps towards a resolution of a grievance concerning sheets not being changed on shower days for three (3) of six (6) meeting minutes reviewed. Meeting dates of 3/11/25, 4/7/25, and 5/6/25

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to honor a resident's right to make healthcare decisions for one (1) of twenty-four residents reviewed for Advance Directives (Resident #53).

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to provide the required Advanced Beneficiary Notice to residents discharged from Part A and continued to live in the facility and had skilled benefit days remaining for two (2) of three (3) residents reviewed for Advanced Beneficiary Notice.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to safely store medications two (2) of (5) five residents medications observed. (Resident #5 and #56)

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to utilize standard precautions with glove use during medication administration for Resident #35 and failed to use Enhanced Barrier Precautions (EBP) during catheter care for Resident #55 for two (2) of six (6) resident care areas observed. The scope for F 880 was increased to E due to a prior citation on the last annual recertification survey on 2/20/24, which represents a pattern of deficiency.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review, the facility failed to honor a resident's right to be treated with dignity and respect for two (2) of four (4) residents reviewed for resident rights.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review, the facility failed to make prompt efforts to resolve and thoroughly investigate grievances from Resident Council meetings for eight (8) of the last nine (9) Resident Council meetings.

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to protect the resident ' s right to be free from physical, verbal, and mental abuse by staff for one (1) of three (3) residents reviewed for abuse.

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to control pain for a resident who was experiencing moderate to intense pain for one (1) of three (3) residents reviewed for pain medication administration. Resident #3 Record review of facility policy titled Medication Administration - General Guidelines dated 8/25/14, revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices .2. Administration . b. Medications are administered in accordance with written orders of the attending physician . During an interview on 8/13/24 at 9:10 AM, Resident #3 revealed she had Multiple sclerosis, Lupus, Arthritis, and Chronic pain and was on a pain medication regimen every four hours around the clock and this regimen kept her pain controlled, but if I miss even one dose, it sets me back for a week. [...]

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to have available and administer an ordered medication for pain control for one (1) of three (3) residents reviewed for pain medication administration.

Inspectors wroteBased on Resident Representative and staff interviews, record review, and facility policy review, the facility failed to make prompt efforts to resolve a grievance and communicate the steps towards a resolution of the grievance concerning call lights not being answered timely for two (2) of five (5) monthly Grievance/Concern Logs reviewed.

Inspectors wroteBased on staff interviews, record reviews, and facility policy review, the facility failed to ensure a resident was kept free from an accident resulting in an injury during facility transport for one (1) of (4) residents reviewed for accidents. Resident #1.

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to protect a residents right to be free from neglect for two (2) of three (3) residents sampled for abuse, Resident #13 and Resident #20 as evidence by: 1) neglected to recognize, communicate, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious serious harm, serious injury, serious impairment, or possibly death. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and job description review, the facility failed to be administered in a manner that ensured residents with significant weight loss would get the necessary nutritional support and services to ensure their well-being for two (2) of three (3) residents sampled for abuse/neglect as evidenced by: Resident #13 and Resident #20 1) failed to recognize, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. [...]

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review, the facility failed to notify the physician for a significant change in condition for two (2) of six (6) residents sampled for nutrition Resident #20 and Resident #13 as evidenced by: 1) failed to recognize, evaluate, communicate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% (percent) in four (4) months. Resident #13. The facility's failure to notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, or possible death. [...]

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to implement a comprehensive care plan for five (5) of eighteen sampled residents as evidenced by: Resident #13, #15, #20, #26, and #54 1) failed to implement the nutritional care plan for Resident #13 which resulted in a significant weight loss which placed the resident at risk for dehydration, malnutrition, skin breakdown and placed the resident and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. [...]

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to maintain acceptable parameters of nutrition for two (2) of six (6) residents sampled for nutrition as evidence by: Resident #13 and Resident #20 1) failed to recognize, evaluate, and address a resident's nutritional needs, which resulted in an unintended significant weight loss of 6.92% (percent) in one (1) month, which further led to a significant weight loss of 17.52% in four (4) months. Resident #13. The facility's failure to consult a Registered Dietician (RD), notify the attending physician of a significant change in condition, and act upon the residents' weight loss, placed the resident, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed maintain an effective Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and address residents with weight loss for two (2) of six (6) residents reviewed for nutrition. Resident #13 and Resident #20. The facility's Quality Assurance and Performance Improvement (QAPI) review indicated the facility's failure resulted in a lack of action to identify and address weight loss, which placed Resident #13 and Resident #20, and all other residents residing in the facility at risk for serious harm, serious injury, serious impairment, and possibly death. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, facility policy review, and job description review, the facility failed to recognize and assess risk factors for a resident receiving an opioid pain medication and failed to ensure that a resident received care in accordance with professional standards of practice, for one (1) of two (2) residents reviewed for pain management. Resident #20. Resident #20 experiencing prolonged nausea, vomiting, and an infrequent passage of stool (constipation) with a potential outcome for fecal impaction, and bowel obstruction (blockage). Findings Include: Record review of the facility policy titled Change in a Resident's Condition or Status with a review date of 7/24/23 revealed Policy Statement: [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure qualifying certifications were held by the Dietary Manager during ten (10) of 10 days of survey.

Inspectors wroteBased on staff interview, record review, and facility procedure review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Fourth quarter 2023.

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to ensure the medication error rate was five (5) percent (%) or less for two (2) of twenty-six medication opportunities. Findings Include: Review of the facility's Med Error Rate following reconciliation indicated the medication error rate was 7.69% (percent). Record review of the facility policy review titled Medication Administration-General Guidelines with a revision date of 8/25/14 revealed PROCEDURE: . 2. Administration: . b. Medications are administered in accordance with written orders of the attending physician . 3. Documentation: a. The individual who administers the medication dose records the administration on the resident's MAR (Medication Administration Record) directly after the medication is given. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free of any significant medication errors for one (1) of eleven medication administration observations. Resident #211 Findings Include: Record review of the facility policy review titled Medication Administration - General Guidelines with a revision date of 8/25/14 revealed .PROCEDURE: .Documentation: a. The individual who administers the medication dose records the administration on the resident's MAR (Medication Administration Record) directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented . [...]

Inspectors wroteBased on observation, staff and family interview, record review, and facility policy review, the facility failed to identify a bed rail as a physical restraint and restricted a resident's freedom of movement for one (1) of 28 sampled residents. Resident #15 Findings Include: Record review of the facility policy titled Physical Restraints dated 4/23/12 revealed Policy: It is the policy of this facility that residents have the right to be free of physical restraints not required to treat the resident's medical symptoms. Physical restraints are not to be used for the convenience of the staff or as punishment of the resident. Physical restraints or safety devices are only used to enable and/or promote functional independence of the resident after consultation with a physical or occupational therapist, upon order of physician, and discussion with the resident's responsible party . [...]

Inspectors wroteBased on staff and resident interview, record review, and facility policy review, the facility failed to investigate and report an allegation of abuse for one (1) of 18 residents sampled.

Inspectors wroteBased on staff interviews, record review, and facility policy review the facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for a Resident, as evidenced by incorrectly coding anticoagulant medication usage during the 7-day observation look-back period for one (1) of four (4) residents sampled for anticoagulant use.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure delivery of care met professional standards of nursing practice for a resident receiving continuous oxygen for one (1) of five (5) residents reviewed with continuous oxygen. Resident #15 Findings Include: Record review of the facility policy titled Change in a Resident's Condition or Status with a review date of 7/24/23 revealed, Policy Statement: Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .Policy interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . f. refusal of treatment or medications two (2) or more consecutive times) . [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADLs) were assisted with personal hygiene as evidenced by long, jagged nails with brown substance underneath nails and unshaven facial hair for three (3) of eighteen residents sampled. Resident #11, Resident #26, and Resident #54

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to follow the physicians order for continuous oxygen usage for one (1) of five (5) residents reviewed for continuous oxygen. Resident #15 Findings Include: Record review of the facility policy titled Oxygen Administration dated 8/25/14, revealed . Preparation: 1. Verify that there is a physician's order for this procedure . Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: . 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. Reporting: 1. Notify the supervisor if the resident refuses the procedure . [...]

Inspectors wroteBased on observation, family and staff interview, record review, and facility policy review, the facility failed to perform an accurate bed rail assessment, and failed to ensure that the bed rails did not pose a risk of injury for one (1) of 28 residents sampled. Resident #15 Findings Include: Record review of the facility policy titled Bed Rails dated 5/10/17 revealed Policy Statement: It is the policy of this center to limit the use of bed rails and similar devices unless the benefit outweighs the risk. No rails of any type will be applied to a bed without prior assessment as to the appropriateness of the use and the device selected. This policy applies to the use of any type of rail attached to the bed, for any purpose. This includes side rails, half rails, quarter rails, split rails, assist rails, enabler bars ect., whether full or partial length. [...]

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to ensure an employee maintained a current Certified Nurse Aide (CNA) certification for one (1) of twenty-seven Certified Nurse Aide certifications reviewed.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure hand hygiene was performed during medication pass to prevent the spread of infection for four (4) of eleven residents observed during medication pass. Resident #20, Resident #48, Resident #55, and Resident #211 Findings Include: Record review of the facility policy titled Handwashing dated June 1, 2000, revealed Policy Statement: It is the policy of this facility that handwashing be regarded as the single most important means of preventing the spread of infection. Procedure: 1. All personnel shall wash their hands to prevent the spread of infection and disease to other residents, personnel, and visitors 7. Alcohol gel may be used during med pass for three times before washing hands. [...]

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident had access to the call light system for (1) of 60 residents on initial tour. Resident #8.